2015 CAMC GIT – Gastrointestinal Tract Infection Worksheet
Name
DOB
MR #
Age
Account #
Admitting Diagnosis
M
F
Birthweight (gms)
(Neonates only)
Test Period
Unit
Event Date
Medicare ID #
Pt expire
Yes No
Admit date
D/C date
ICU Admit date
ICU D/C date
Attending / ID Consultant
Culture date
Pathogen(s)
Culture Site
Culture date
Pathogen(s)
Culture Site
GIT- Gastrointestinal tract infection (esophagus, stomach, small and large bowel, and rectum) excluding gastroenteritis, appendicitis, and C. difficile
infection
Gastrointestinal tract infections, excluding gastroenteritis and appendicitis, must meet at least one of the following criteria:
Date
1.
2.
Patient has an abscess or other evidence of infection on gross anatomic or histopathologic exam of gastrointestinal tract.
Patient has at least two of the following localized signs or symptoms compatible with infection of the organ or tissue involved: fever
(>38.0°C±), nausea*, vomiting*, pain*or tenderness*, odynophagia*, or dysphagia*
AND at least one of the following:
a. Organisms cultured from drainage or tissue obtained during an invasive procedure or from drainage from an
aseptically-placed drain
b. Organisms seen on Gram stain or fungal elements seen on KOH stain or multinucleated giant cells seen on microscopic
examination of drainage or tissue obtained during an invasive procedure or from drainage from an aseptically-placed
drain
c. Organisms cultured from blood in a patient with imaging test evidence of gastrointestinal infection
d.
Imaging test evidence of infection (e.g., MRI, CT Scan)
e. Evidence of infection on endoscopic examination (e.g., Candida esophagitis, proctitis, etc.)
* With no other recognized cause
± As documented in the medical record
Notes/Comments:
2015 CAMC GIT – Gastrointestinal Tract Infection Worksheet
Unit
RIT
Infection
Window
Period
Date of Event
Hospital
Day
Date
Table of Events
Infection Window Period (first + diagnostic test, 3 days before & 3 days after) Repeat Infection Timeframe-RIT (14 day timeframe where date of event = day 1)
Date of Event (date the first element occurs for the first time within the infection window period) Secondary BSI Attribution Period (Infection Window Period + RIT)